All photographs by Stacy Kranitz
It's 1 AM at the gates of a fairground on a foggy former strip mine in rural southwest Virginia, and Michael Willis has just been given a ticket that could save his life. He's number 1,135, meaning he's the 1,135th person to seek free medical care this morning at the Remote Area Medical Clinic (RAM). And there are hundreds more waiting in the dark behind him.
Willis has been coughing up blood. A former coal miner, his lungs are a wreck, but he says his insurance won't cover the medicine he needs. A metal coil implant in his lung is keeping him breathing, and he's afraid it's going to pop out. He also needs a bad tooth pulled.
By 9 AM, the mist has burned off the top of the mountain, the temperature is climbing toward a humid 86 degrees, and Willis's tooth has been yanked by a volunteer in an open-air dental unit. He sits on some bleachers in a bit of a daze, gums oozing blood.
His numb mouth finds the words: "There would be a lot of people hurting if this didn't exist."
The Remote Area Medical Clinic is a vast open-air mash unit staffed by 1,200 volunteers from all over the country that appears in Wise, Virginia, every summer. In 2015, when I was there, they performed 7,035 dental procedures and gave away 840 pairs of glasses to 2,172 people who couldn't otherwise afford them. Dozens of other medical services were on offer: EKGs, ultrasounds, endocrinology, orthotics—all of it free. In a region where specialists are rare, demand is incredibly high. Would-be patients camp out for multiple nights to stake their spots in line, endure intense heat on top of their pain, and sometimes wait all day for treatment.
"Stop the Suffering" demands the sign at RAM's gate. First you file your paperwork in a large canvas tent, and fans at hurricane force to keep down the heat. Then you arrive at triage, housed in a slightly more permanent structure, where you get some basic tests like blood pressure and blood sugar. This is like any doctor's pre-exam room, except for hand-painted head-in-the-holes of Little Bo Peep and her sheep hanging from the rafters, in storage until the next county fair. Animal stalls line the walls—that's where you're temporarily quartered if there's a problem during your checkup. Maybe you drank too much coffee or smoked too many cigarettes, and your blood pressure's up, or maybe you're having a bona fide medical emergency.
If your pre-exam is normal, you move on to a large rodeo arena to wait until your number is called. There's grumbling here and there, but by and large those gathered are immensely grateful for the care they receive at RAM. In the arena throughout the event, gospel quartets croon standards like "Rank Stranger" and "I Saw the Light" in an effort to ease the day's trials.
"You dread the lines, but we don't mind coming here at all," says Michael's wife, Tonya Willis, a diabetic seeking medical supplies. This is the couple's fifth year at the clinic. "We're just thankful."
To see such massive lines for basic medical care in America today is startling and alarming. Why is there this kind of need? Why hasn't anyone filled this regional hole is the nation's patchwork healthcare system? Didn't Obamacare help at all?
In a crisp white shirt and cane hat, Dr. Joe Smiddy—a veteran pulmonologist out of nearby Kingsport, Tennessee, and medical director of the Health Wagon, a mobile clinic that provides care to people in the area—rests for a moment in a tent in front of the motor home he's converted into a mobile X-ray unit. He has been examining black lung patients and smokers all day at the RAM clinic.
In a country doctor's drawl, he provides a pretty apt summary: "There's the story of who we are—geographically, medically, economically—and then there's the story of the healthcare system."
The "we" he refers to are the people of Central Appalachia—a mountainous subregion where the edges of Kentucky, Virginia, West Virginia, and Tennessee come together.
It's an overwhelmingly rural place where amenities can be a long ways away from home. Reaching a doctor can mean driving on steep, twisted roads for an hour or more, which takes money, time, and a car you may not have—one of the reasons that Smiddy drives his X-ray unit to his patients in their own communities instead of assuming they can come to him.
A 2008 ranking by Gallup-Healthways ranked all the congressional districts in the country for physical health. The four worst comprise basically all of Central Appalachia. Randy Wykoff, dean of the East Tennessee State University College of Public Health, spends a lot of time breaking that down for people. Consider, he says, the five factors that contribute to premature death, according to a 2007 study published in the New England Journal of Medicine: behaviors (40 percent), genetics (30 percent), social circumstances (15 percent), health care (10 percent) and environmental exposures (5 percent).
Now consider that Central Appalachia has some of the highest rates of tobacco use, obesity, diabetes, and other preventable diseases (behaviors) in the country. Couple that with some of the highest poverty rates (social circumstances), and the picture starts to come into focus.
Then there's the matter of politics: Virginia is one of 19 states that haven't adopted Medicaid expansion under the Affordable Care Act. Many on this mountain are among the more than 3 million Americans and 171,000 Virginians who fall into the coverage gap—they don't have the money to buy a plan, even under Obamacare, but they don't qualify for Medicaid either.
Eva Slover once helped people enroll in Medicaid. She lost her job and finds herself in line at the RAM clinic seeking vision care, a little overwhelmed and wearing impractical shoes.
"I see now what people go through. I didn't realize…" she trails off. "Now I'm on the side of the people. Now I see the struggles they go through and it shocks me."
Mark Mullins is among thousands of laid off coal miners in Central Appalachia. He and his wife Sarah, say that if they both got minimum-wage jobs, they'd lose food assistance benefits and their children's Medicaid coverage, forced to choose between paying the bills and feeding their three children. So they stay "on the draw," unsure about a way forward.
"We're basically stuck between a rock and a hard place," says Mark.
Equally as persistent as the gap is its close cousin, the loop.
"The loop gets a lot more people here than you could possibly think. The loop is what puts us here," says Shannon Dwyer, who is in line to have her eyes examined in a darkened warehouse building among the blinking pen lights of about two dozen volunteer optometrists.
By "the loop," she means all the ways that people are denied care by intricate webs of insurance, judicial, and government procedure, jounced from office to office in what can be a long and grueling chase to obtain relief. It takes determination to persist, and some people here lack the capacity, patience, or resources to successfully navigate all the red tape. Some are simply too sick. And many have developed animosity and distrust towards a system that was ostensibly set up to serve them.
"By the time someone gets to RAM, there has been a failure in the system," says Dr. Wykoff.
RAM can't provide ongoing or preventative care; it's a stopgap measure, not a solution to the health-related problems plaguing the region. When people step out of the tents, they're back on the outskirts of the system, or totally detached from it.
Here's the good news: In the midday heat, surrounded by the whine of 50 dental drills, Fred Moore of Rose Hill, Lee County, Virginia, is about to have his jaw bone shaved so he can finally be fitted for dentures.
Dr. Jeffrey Cyr swats and kills a wasp that landed on his operating station. A nurse wipes it down before welcoming Moore to the chair.
"I've got a hard head," Fred warns. "You've got a big sledgehammer, don't you?"
"That's not what I want to hear right now," replies Cyr, smiling as he palpates Moore's baby-smooth gums. As it turns out, he will end up needing some pretty heavy-duty dental hammers and saws to do this operation.
Moore, a soft-spoken 57-year-old with a tattoo of a heart on his middle finger and a pure white mullet, makes friendly jokes despite his dread. Other patients lay supine around him, floppy-mouthed and swollen in various stages of their operations.
Pairs of youth in surgical smocks wander with sloshing buckets of yellow enzyme solution to flush blood and bits of bone from the tubes between patients.
Thankfully, Moore has absolute trust in the medical volunteers here. He drives 80 miles to receive ongoing free care from an eye doctor he met at RAM who diagnosed the glaucoma that almost blinded him.
Moore was disabled in a yard work accident in '96, has hepatitis C, and recently had prostate surgery. All of his teeth were pulled at the same time seven years ago, rotten from a lack of preventative care. If RAM didn't exist, he'd go on doing without.
Fred Moore and thousands like him are served here, year after year. While they wait for their number to come up on a dental procedure, they might wander over to get a mammogram or spend some time in the education tent.
"There's a lotta shade in here, so come on in for smoking cessation, followed up by mouth cancers at four o'clock!" cries the tent's health carnival barker to the crowd. Inside, a woman does a sex-education workshop on cervical cancer using 3D models of women's reproductive equipment. Gift cards and stitched yarn crosses are distributed to those in attendance.
The barker throws a little love to the osteopathic tent across the midway: "If your spouse can't manipulate you, go on over there and let them jump your bones!"
The atmosphere, while not exactly festive, is one of affectionate commiseration. Sno-cones and bag lunches are distributed by church groups. People gab with neighbors. Backs are realigned.
"I gave the ladies who checked my blood pressure two angels made of coal," says Laurence Hall of Big Stone, Virginia, as he embraces local diabetes educator Lona Roberts. A military reservist who's also a big hugger, Hall came for dentures and stayed for a diabetes diagnosis. He's overflowing with thanks for counsel on managing his new disease: recipes, exercises, and other tools.
Several people describe it as the big-box store equivalent of health care, a one-stop-shop for relief. And indeed, the medical community is starting to talk about the "patient-centered medical home" or a "one-door policy," the idea that the fewer places you have to go to get your needs met, the more efficient the system can be. Food vouchers, a specialist referral, and insurance applications, for example, could one day be sought from a simpler, more complete, system entry point. There's a chance that this fairground is a glance at the future of care.
Being treated in animal stalls could be seen as dehumanizing, but so could the cracks in the system that got people here in the first place. Much more than a sob story, RAM is a scene of people taking good and serious care of each other because it's the right thing to do.